Epsom Hospital boss apologises as coroner rules new born's death came after diagnosis errors

Dr Karen Henderson, assistant coroner for Surrey Coroner Court, Woking, said opportunities were missed to diagnose Micah Smith with hydrocephalus - a condition in which excess fluid puts pressure on the brain and causes irreparable damage.

Doctors said its diagnosis and appropriate treatment could have saved the child’s life.

Micah died from hydrocephalus on July 15, 2013 in St George's Hospital, Tooting.

He and his twin brother Isaac were born on June 13 by emergency caesarean in East Surrey Hospital and discharged shortly afterwards.

But after he had problems feeding, a tongue tie separation procedure was carried out on June 25.

Mum Lisa Smith told the court on Wednesday that after the procedure he "went pale and his eyes rolled".

- Mother of Micah Smith describes son's treatement as "utterly terrible"

He was then taken to Epsom Hospital where a lumbar puncture and an ultrasound scan for meningitis and gastroesophageal reflux were carried out and both tested negative.

By July 13 his condition had worsened and his head had swollen.

He was rushed to St George’s Hospital but doctors were unable to save his life.

Mrs Smith told the court she felt her fears for her son were dismissed as "neurotic".

Independent consultant neonatologist Dr Neil Aiton questioned whether Mrs Smith’s concerns were acted upon.

He said: "There seemed to be a disparity between parental concern and what the nurses were recording and what the doctors were perceiving."

Dr Aiton also told the court he felt there was an "undue reliance" on tests for gastroesophageal disease and cardio and respiratory observations.

He believed administering the tests were the "right thing to do" given the symptoms, but that staff could have done more.

He said: "Considering the cardio and respiratory dimension of the symptoms a working diagnosis of gastroesophageal reflux disease was perfectly reasonable.

"But I think there was more going on in an unwell baby that required further thought."

Dr Aiton believes timely diagnosis of the condition would have increased the chances of Micah being properly treated.

He said: "The most straightforward thing to have done when you have a baby who is admitted and is not feeling well is to measure the head circumference.

"That would almost certainly shown hydrocephalus.

"The failure to diagnose that sooner left Micah without a clear chance of survival."

Dr Nicola Paul, paediatric registrar at Epsom Hospital said: "I think we should have monitored Micah’s head circumference on each admission.

Dr Matthew Crocker, consultant neurosurgeon at St George’s Hospital described Micah’s head as "unusually large" when arrived at the ICU.

He said: "If the hydrocephalus had been picked up it is more than likely that he would have survived the incident."

Joint Medical Director and Deputy Chief Executive at Epsom Hospital, Dr Ruth Charlton, apologised for the trusts failings.

She said: "On behalf of the trust, I would like to offer my heartfelt condolences to the family and loved ones of Micah Smith.

"We are deeply sorry that the care provided to Micah fell short of the standards that we would expect for our patients.

“Since this case, we have introduced a number of steps to reduce the risk of a similar occurrence ever happening again in future, including recruiting an additional four acute paediatric consultants to bolster our clinical capacity in this area.

“We have also introduced a Children’s Observation and Severity Tool – an observation and early warning system to help our staff identify unwell children quickly so that opportunities for early diagnoses are not missed.”

Dr Karen Henderson, assistant coroner for Surrey, delivered a narrative verdict on how Micah died.

She said: "Micah died from hydrocephalus secondary to raised intracranial pressure arising from naturally occurring intra-ventricular haemorrhage.

"There was a delay in diagnosis and consequently effective treatment could not have been instituted."